Medicare Plan Lookup Official CMS data · Contract Year 2027
CMS 2027 data

2027 Medicare plan code

H3012-002

Medicare Plan

St. Luke's Advantage Rx 02 (HMO) · St. Luke's Advantage · HMO · Blaine and Valley counties

Full CMS plan ID: H3012-002-000

H3012-002-000 is the full CMS identifier for the H3012-002 Medicare plan. Common searches include H3012 002 and H3012002.

2027

Spaces or dashes work: H5216-435-002 · S2135 802

● CMS 2027 plan record

St. Luke's Advantage Rx 02 (HMO)

H3012-002-000 Blaine and Valley counties HMO

At-a-glance

Quick view

01

In-network

Inpatient hospital

Days 1–5 $400 / day
Days 6–90 $0 / day
Total of listed copays · 5 charged days $2,000
Out-of-network

Not separately reported

Point of service

Not separately reported

02

Emergency transport

Ambulance

Ground · in-network$295 copay
Air · in-network$295 copay
03

Emergency services

Emergency room

$130 copay

Waived if admitted within 24 hours

04

Medical maximum

Maximum out-of-pocket

In-network$6,950
Combined in + outNot reported
05

Skilled care at home

Home health

In-network$0 cost share
Out-of-networkNot separately reported
06

Monthly cost

Premium & giveback

Part C premium$37.50 / month
Consolidated C + D$142 / month

CMS reports no Part B premium reduction for this plan.

Plan details

All plan benefits

Medical care3 benefits

Primary care physician

In-networkPrimary Care Physician Services: $0 cost share
Out-of-networkNot separately reported

Specialist

In-networkPhysician Specialist Services: $0–$30 copay
Out-of-networkNot separately reported

Preventive care

In-networkAnnual Physical Exam: $0 cost share; Kidney Disease Education Services: 20% coinsurance; Glaucoma Screening: $0 cost share; Diabetes Self-Management Training: $0 cost share; Digital Rectal Exams: $0 cost share; EKG following Welcome Visit: $0 cost share
Out-of-networkNot separately reported
Diagnostics & imaging4 benefits

Diagnostic procedures & tests

In-networkDiagnostic Procedures/Tests: 0%–20% coinsurance
Out-of-networkNot separately reported

Laboratory services

In-networkLab Services: 0%–20% coinsurance
Out-of-networkNot separately reported

X-rays & standard imaging

In-networkOutpatient X-Ray Services: $0–$15 copay
Out-of-networkNot separately reported

MRI, CT & PET imaging

In-networkDiagnostic Radiological Services: $0–$300 copay
Out-of-networkNot separately reported
Urgent & hospital care6 benefits

Urgent care

In-networkUrgently Needed Services: $30 copay
Out-of-networkNot separately reported

Emergency room

In-network$130 copay
Out-of-networkNot separately reported

Ground ambulance

In-network$295 copay
Out-of-networkNot separately reported

Air ambulance

In-network$295 copay
Out-of-networkNot separately reported

Outpatient hospital

In-networkOutpatient Hospital Services: $0–$400 copay; Observation Services: $400 copay
Out-of-networkNot separately reported

Outpatient surgery / ASC

In-networkAmbulatory Surgical Center (ASC) Services: $0–$400 copay
Out-of-networkNot separately reported
Recovery & therapy5 benefits

Home health

In-network$0 cost share
Out-of-networkNot separately reported

Skilled nursing facility

In-networkSkilled nursing facility: Tier 1: $0 / day for days 1–20; $221 / day for days 21–100
Out-of-networkNot separately reported

Cardiac & pulmonary rehabilitation

In-networkCardiac Rehabilitation Services: $0 cost share; Intensive Cardiac Rehabilitation Services: $0 cost share; Pulmonary Rehabilitation Services: $0 cost share; SET for PAD Services: $0 cost share; 3-1(NMC): Not applicable; 3-2(NMC): Not applicable; 3-3(NMC): Not applicable; 3-4(NMC): Not applicable
Out-of-networkNot separately reported

Occupational therapy

In-networkOccupational Therapy Services: $20 copay
Out-of-networkNot separately reported

Physical & speech therapy

In-networkPhysical Therapy and Speech-Language Pathology Services: $20 copay
Out-of-networkNot separately reported
Behavioral health2 benefits

Mental health services

In-networkPartial Hospitalization Program: $75 copay; Individual Sessions for Mental Health Specialty Services: $0 cost share; Group Sessions for Mental Health Specialty Services: $0 cost share; Individual Sessions for Psychiatric Services: $0 cost share; Group Sessions for Psychiatric Services: $0 cost share; Inpatient psychiatric hospital: Tier 1: $400 / day for days 1–5; $0 / day for days 6–90
Out-of-networkNot separately reported

Substance use treatment

In-networkIntensive Outpatient Program Services: $75 copay; Individual Sessions for Outpatient Substance Abuse: $0 cost share; Group Sessions for Outpatient Substance Abuse: $0 cost share
Out-of-networkNot separately reported
Specialty care2 benefits

Podiatry

In-networkPodiatry Services: $30 copay; 7f(NMC): $30 copay
Out-of-networkNot separately reported

Chiropractic

In-networkChiropractic Services: $15 copay
Out-of-networkNot separately reported
Supplemental benefits7 benefits

Dental

In-networkMedicare Dental Services: $0 cost share; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 cost share; Dental X-Rays: $0 cost share; Other Diagnostic Dental Services: $0 cost share; Prophylaxis (Cleaning): $0 cost share; Other Preventive Dental Services: $0 cost share
Out-of-networkNot separately reported

Vision

In-networkEye Exams: $0 cost share; Routine Eye Exams: $0 cost share; Other Eye Exam Services: $0 cost share; Eyewear: $0 cost share; Contact Lenses: $0 cost share; Eyeglasses (lenses and frames): $0 cost share; Eyeglass lenses: $0 cost share; Eyeglass frames: $0 cost share; Upgrades: Not applicable
Out-of-networkNot separately reported

Hearing

In-networkHearing Exams: $0 cost share; Routine Hearing Exams: $0 cost share; Fitting/Evaluation for Hearing Aid: $0 cost share; Prescription Hearing Aids (all types): $0 cost share; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable
Out-of-networkNot separately reported

Transportation

Not applicable
In-network10b(NMC): Not applicable
Out-of-networkNot separately reported

Fitness & wellness

Not applicable
In-networkFitness Benefit: Not applicable
Out-of-networkNot separately reported

Over-the-counter allowance

Not applicable
In-networkOver-the-Counter (OTC) Items: Not applicable
Out-of-networkNot separately reported

Meals

Not applicable
In-networkMeal Benefit: Not applicable
Out-of-networkNot separately reported
Plan costs & rulesCoverage overview

Premium & Part B giveback

$37.50 Part C premium / month · CMS reports no Part B premium reduction for this plan.

Maximum out-of-pocket (MOOP)

In-network$6,950
Combined in + outNot reported

Medical deductibles

In-network$500
Out-of-networkNot reported

Annual health deductible

Not separately reported

Combined network deductible

Not separately reported

Part D premium

$104.50 / month

Network & referrals

HMO · Referrals: Not required · Out-of-network coverage: Not reported

Prescription drugs5 tiers

Part D deductible

$299 / year

Drug tier 1

Standard retail: $0 copay · Preferred retail: $0 copay · 30-day supply

Drug tier 2

Standard retail: $5 copay · Preferred retail: $5 copay · 30-day supply

Drug tier 3

Standard retail: 25% coinsurance · Preferred retail: 25% coinsurance · 30-day supply

Drug tier 4

Standard retail: 35% coinsurance · Preferred retail: 35% coinsurance · 30-day supply

Drug tier 5

Standard retail: 30% coinsurance · Preferred retail: 30% coinsurance · 30-day supply

Using this plan

Understand H3012-002-000

Plain-language context built from this plan’s 2027 CMS record. It is a guide to the reported benefits, not a personalized cost estimate.

Plan at a glance

A quick read on this plan

St. Luke's Advantage Rx 02 (HMO) is a 2027 HMO offered by St. Luke's Advantage in Blaine and Valley counties. The plan record does not require referrals. Its listed inpatient copay stages total $2,000 across 5 charged days.

Common benefit costs

What you may pay

These are individual in-network benefit amounts. A real visit may involve more than one separately billed service.

Routine care

Primary care physician
Primary Care Physician Services: $0 cost share
Specialist
Physician Specialist Services: $0–$30 copay
Laboratory services
Lab Services: 0%–20% coinsurance

Separate visits or services; costs are not added together.

Tests & outpatient care

Diagnostic procedures & tests
Diagnostic Procedures/Tests: 0%–20% coinsurance
MRI, CT & PET imaging
Diagnostic Radiological Services: $0–$300 copay
Outpatient hospital
Outpatient Hospital Services: $0–$400 copay; Observation Services: $400 copay

The service setting and billing details can change what you pay.

Emergency & hospital care

Emergency room
$130 copay
Listed inpatient stages
$2,000 total

5 charged inpatient days are included in the calculated total. Actual costs depend on the care received and plan rules.

Helpful context

Terms worth knowing

Maximum out-of-pocket (MOOP)

This is the most you generally pay during the plan year for covered Part A and Part B medical services under the applicable network limit. Premiums and prescription drug costs generally do not count toward it.

Part B premium reduction (“giveback”)

A giveback may reduce the amount you pay toward Medicare Part B; it is not usually paid to you as cash. The CMS record notes: CMS reports no Part B premium reduction for this plan.

Availability

Who can enroll

Service area
Blaine and Valley counties (ID)
Plan type
HMO
Contract / plan
H3012-002
Coverage year
2027

Enrollment generally requires Medicare eligibility and residence in the plan's service area. Confirm eligibility and the exact service area with the plan before enrolling.

Supplemental coverage

Extra benefits reported

Availability is summarized here; allowances, frequency limits, networks, and prior-authorization rules may apply.

DentalMedicare Dental Services: $0 cost share; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 cost share; Dental X-Rays: $0 cost share; Other Diagnostic Dental Services: $0 cost share; Prophylaxis (Cleaning): $0 cost share; Other Preventive Dental Services: $0 cost share
VisionEye Exams: $0 cost share; Routine Eye Exams: $0 cost share; Other Eye Exam Services: $0 cost share; Eyewear: $0 cost share; Contact Lenses: $0 cost share; Eyeglasses (lenses and frames): $0 cost share; Eyeglass lenses: $0 cost share; Eyeglass frames: $0 cost share; Upgrades: Not applicable
HearingHearing Exams: $0 cost share; Routine Hearing Exams: $0 cost share; Fitting/Evaluation for Hearing Aid: $0 cost share; Prescription Hearing Aids (all types): $0 cost share; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable

Plan-specific answers

Frequently asked questions

Where is H3012-002-000 available?

St. Luke's Advantage Rx 02 (HMO) is listed for Blaine and Valley counties (ID). Enrollment generally requires Medicare eligibility and residence in the plan's service area.

What is the in-network maximum out-of-pocket limit for H3012-002-000?

The 2027 CMS record lists an in-network medical maximum out-of-pocket limit of $6,950. Prescription drug spending generally does not count toward this medical limit.

What is the monthly plan premium for H3012-002-000?

The listed consolidated Part C and Part D premium is $142 per month. This does not replace the standard Medicare Part B premium.

What does an emergency room visit cost on H3012-002-000?

The plan record lists $130 copay, waived when an admission meets the plan's stated timing rule.

Does H3012-002-000 report extra benefits?

Yes. CMS reports dental, vision, hearing. See the detailed benefit rows and official plan documents for limits and conditions.

Source trail

Official CMS, Contract Year 2027

Plan identity and benefits come from CMS PBP data. Benefits and drug cost sharing come from the approved annual PBP tabular extract and its CMS dictionary. Premiums and drug deductibles are cross-checked with the annual Landscape. Geography comes from annual PlanArea and PlanRegionArea records, including exact segments and partial-county or employer/group qualifiers. Quick-reference values should be confirmed in current official plan documents.

PBP benefits ↗ Landscape data ↗ County service area ↗

Plan context

Where H3012-002-000 fits

Full CMS plan ID
H3012-002-000
Contract
H3012
Base plan code
H3012-002
Segment
000
Carrier
St. Luke's Advantage
Plan type
HMO
Service area
Blaine and Valley counties (ID)

County/service-area foundation

CMS service-area entries

Service areas come from the annual CMS PlanArea and PlanRegionArea tables for this exact contract, plan, and segment. Partial-county and employer/group qualifiers remain part of the coverage area. Regional PPO county entries use the matching annual Landscape expansion of the CMS region.

  • Blaine, ID
  • Valley, ID

Exact county navigation

These links are limited to named counties tied to this exact medical plan segment. Partial-county entries remain labeled for verification.

Show 2 county links

Same CMS contract

H3012-001-000 St. Luke's Advantage Rx 01 (HMO) Ada, Canyon, and Elmore counties · HMO H3012-003-000 St. Luke's Advantage Rx 03 (HMO) Jerome and Twin Falls counties · HMO

About this code

What H3012-002-000 identifies

H3012-002-000 is a Contract Year 2027 Medicare plan segment code. Searches written as H3012-002, H3012 002, or the compact full CMS ID H3012002000 refer to this plan or its base plan code.

Medicare Plan Lookup uses official CMS data as a quick reference. Benefit details, eligibility, service-area rules, and cost sharing should be confirmed in the current Summary of Benefits or Evidence of Coverage.